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California Land Disposal/Restriction Information Notification/Certification Form This form is submitted In accordance with the requirements of 22 CCR 66268.7(a) Chapter 18 which restricts land disposal of certain hazardous wastes. The appropriate California waste code(s)and applicable non-RCRA hazardous waste listings from CCR 66268.29 are noted below.Complete all portions of Part I. if the waste is non-hazardous or not restricted then complete only the applicable portions in Part I and sign i date the Form at the bottom of page. Otherwise complete Part 1,II,and III,and sign/date the Form at the bottom of page. 1. GENERAL INFORMATION REGARDING GENERATOR&WASTE STREAM GENERATOR'S NAME Lawrence Livermore National Laborato PHONE: 925-422-1925 SITE LOCATION: Corral Hollow Rd.Tracy,CA 95176 PROFILE NUMBER: DOP0065-1 IS THIS WASTE NON-HAZARDOUS 7®NO, OYES(if YES,stop here and signidate form at the bottom of page) GENERATOR'S EPA ID#: CA2890090002 MANIFEST#: 005871009JJK CA WASTE CODE(S): 181 IS THIS WASTE RESTRICTED? []YES ®NO(if NO,stop here and sign/date form at the bottom of page) THIS NOTIFICATION&CERTIFICATION IS BASED ON THE FOLLOWING WASTE STREAM INFORMATION: ❑(A)CHEMiCALiPHYSICAL ANALYSIS OF THE WASTE; ❑(B)GENERATOR KNOWLEDGE OF THE WASTE;OR ❑(C)BOTH Check the appropriate boxes in Parts II and III.If only one applies,then 111(A)is not required.For multiple certifications/notifications,the appropriate choices from Part 11(1-3)may be marked in Part IIIA)to Indicate flow waste is to be managed to conform with Land Disposal Restrictions. By selecting an item in Part III(A), 1-3,you are making the certification i notification noted In Part It. II. TYPE OF LOR NOTIFICATION l CERTIFICATION ❑ 1.> NOTIFICATION ONLY: WASTES THAT CURRENTLY REQUIRE TREATMENT TO MEET THE 22 CCR ARTICLE`11 TREATMENT STANDARDS:=*22 CCR§66268.7(a)(1) ❑ 2.>NOTIFICATION&CERTIFICATION:WASTE THAT MEETS THE 22 CCR ARTICLE 11 TREATMENT STANDARDS,NO ADDITIONAL TREATMENT REQUIRED:=*22 CCR 966268.7(a)(2) I certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification,that the waste complies with the treatment standards specified In CCR Title 22,Division 4.5, Chapter 18,Articles 4 and I 1 and all applicable prohibitions set forth in CCR Title 22,Section 66269.32 or RCRA Section 3004(d)(42 U.S.C. Section 69241411.l believe that the information I submitted is true,accurate and complete.l am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment. ❑ 3.>NOTIFICATION&CERTIFICATION: NON-RCRA WASTE THAT HAS BEEN TREATED AT AN OFF-SITE TREATMENT FACILITY SO AS TO MEET ALL APPLICABLE 22 CCR ARTICLE 11 TREATMENT STANDARDS-.=22 CCR 666268.7(b)(5) l certify under penalty of law that 1 personally have examined and am familiar with the waste through analysis and testing through knowledge of the waste to support this certification,that the waste complies with the treatment standards specified in CCR Title 22,Division 4.5, Chapter 18,Articles 4 and 11 and all applicable prohibitions set forth in CCR Title 22,Section 66268.32 or RCRA Section 3004(d)(42 U.S.C. Section 6924(4)1.I believe that the information i submitted is true,accurate and complete.1 am aware that there are significant penalties for submitting a false certification,including the possibility of fine or imprisonment. Ill.LDR NOTIFICATION l CERTIFICATION INFORMATION REQUIRED BY 22CCR Check IA) 18) iCI IDI appropriate Check 1.Z or 3 from Corresponding boxes handling Information Prohibition Subcategory of Restricted Waste(22 CCR 66268.29 a-m1 and Treatment Standard (Pert Iq Effective Date Treatability Groupisi 66268.100(a)i 1.14) (From 22 CCR) 1 ❑ ❑1 ❑2 ❑3 1 26190 Aqueous wastes containing metals 166268.29(dl&66268-t0o(al(1)I 1 66268.107 Table 11 CCW 2 ❑ 0 02 03 58191 Auto shredder waste(66268.29(c)&66268,100(a'11311 2 6626B.106 Table-A CCWE 3 ❑ ❑1 ❑2 ❑3 171191 Hazardous waste foundry sand(6626B.29(e)&66268.100(ali5)I 4 66268.106 Table 1•B CCWE 4 ❑ ❑1 ❑2 03 W131 Fly ash,bottom ash,retort ash or baghouse waste 166268.291h)&66266.1001a)(8)] 7 66268.105 Table 1-0 CCWE s.❑ ❑1 ❑2 ❑3 111191 Baghousewaste from foundries[66268.29'i)&66268.100109)I 8 66268.106 Table VE CwE 6 ❑ ❑1 ❑2 ❑3 311133 Asbestos containing waste identified in section L66268.29(mi&6626B.1001oli131) 12 66268.114 7 ❑ ❑1 ❑2 ❑3 Otheri5pecifyl: 13 Copies of applicaVe treatment standards and waste analysis data(where available)are maintained at the facility identified on the manifest referenced above. IV. GENERATOR AUTHORIZATIONICERTIFICATION I hereby Certify that all Information submitted in this and all associated documents is true,complete,and accurate to the best of my knowledge and Information,and that n missions ore r5 exist.I warrant that I am an authorized representative of the generator. BradleySlinin er Shi in Coordinator 414119 Authorized Signa urs Printed Name Title Date THIS DOCUMENT, WITH AN ORIGINAL SIGNATURE, MUST ACCOMPANY EACH WASTE SHIPMENT. A COPY OF THIS CERTIFICATION, AND ALL SUPPORTING DATA,MUST BE RETAINED BY THE GENERATOR FOR A LEAST FIVE(5)YEARS AS PER 22 CCR§66268.7 Rev.11102 Page 7 of 13